Basic Information
| Provider Information | |||||||||
| NPI: | 1912368176 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | COURAGE TO CHANGE, INC. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 252 HIGH SIERRA DR | ||||||||
| Address2: | |||||||||
| City: | EXETER | ||||||||
| State: | CA | ||||||||
| PostalCode: | 932219502 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5595944855 | ||||||||
| FaxNumber: | 5595940086 | ||||||||
| Practice Location | |||||||||
| Address1: | 1230 N ANDERSON RD | ||||||||
| Address2: | |||||||||
| City: | EXETER | ||||||||
| State: | CA | ||||||||
| PostalCode: | 932219674 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5595944855 | ||||||||
| FaxNumber: | 5595940086 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/16/2016 | ||||||||
| LastUpdateDate: | 03/16/2016 | ||||||||
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| AuthorizedOfficialLastName: | GAMBINI | ||||||||
| AuthorizedOfficialFirstName: | SUSAN | ||||||||
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| AuthorizedOfficialTitleorPosition: | ADMINISTRATOR | ||||||||
| AuthorizedOfficialTelephone: | 5595944855 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 3245S0500X | 540014BN | CA | N | Residential Treatment Facilities | Substance Abuse Rehabilitation Facility | Substance Abuse Treatment, Children | 253J00000X | 247200700 | CA | Y | Agencies | Foster Care Agency |
No ID Information.